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Frequently asked questions about Real-Time Claims
This document anticipates questions providers may have about the Real-Time Claims web tool provided by Blue Shield of California (Blue Shield) on the Provider Connection website. Should you need additional support, please contact Blue Shield Provider Services at (800) 541-6652.
1. Which Blue Shield member plans are supported by the Real-Time Claims tool?
At this time, the Real-Time Claims web tool supports claims submitted for Blue Shield fully insured commercial PPO members who have a single healthcare policy, and HMO member claims for which Blue Shield is financially responsible.
The Real-Time Claims tool does not yet support the following claims:
- Blue Shield of California Promise Health Plan member claims
- Blue Shield HMO claims for which an IPA/medical group or capitated hospital carries financial responsibility.
- Federal Employee Program (FEP), BlueCard, Shared Advantage California, Shared Advantage BlueCard, or dual In-house plan claims
- Any claim for which Blue Shield is not the primary payer
2. When will this tool be available for Blue Shield Promise providers?
We have plans to provide Real-Time Claims to Blue Shield Promise providers in the future. We will inform you as developments are made.
3. How do I get access to Real-Time Claims functionality?
A. If you are already a registered Provider Connection user:
Registered account managers should have access to Real-Time Claims automatically. Other users should contact their account manager to request access. If your account does not have Real-Time Claims access, please contact Blue Shield Provider Services at the number above.
B. If you are not currently a registered Provider Connection user:
- If your organization has a Provider Connection account, ask your account manager to set up a user account for you and grant you access to Real-Time Claims.
- If your organization does not have a Provider Connection account, please register as an account manager. If your account does not have Real-Time Claims access, please contact Provider Services.
4. I’m an account manager – how do I grant Real-Time Claims access to users in my account?
Once account managers have access to Real-Time Claims, they can grant and revoke access for their users. From Provider Connection, go to the Account Management section, then select Manage User Accounts to grant or revoke access for each user.
5. Can my billing service use the Real-Time Claims web tool?
Yes, they just need to have access to Provider Connection to access Real-Time Claims.
6. How is using the Real-Time Claims tool different from the usual claim submission process?
The Real-Time Claims tool provides the following functions:
- Includes an estimator tool to help providers and members understand service costs
- Is faster for processing the claims eligible to be supported (listed in question 1)
- Validates that all required information is included before a claim can be submitted
- Provides a streamlined digital experience
- Requires fewer manual inputs
7. What are the advantages of using the Real-Time Claims tool?
The Real-Time Claims web tool performs these helpful functions:
- Connects directly with the Blue Shield claims processing system, increasing both the speed and accuracy of estimates and claim submissions
- Reduces the transactional burden on providers, creating more time for patient care
- Provides payment assurance by rapidly delivering estimates
- Makes it easy to quickly convert estimates to claims and submit them in seconds
- Automatically prevents incomplete claim submissions, resulting in fewer denied claims
8. Will Real-Time Claims show up on the Claims Status tool in Provider Connection?
Yes, all claims submitted through the Real-Time Claims tool will appear in the Claims Status tool in Provider Connection. You will be able to see all your claims in one place.
9. If I have already submitted a claim through EDI, mail or fax, can I convert it to a Real-Time Claim?
Once you have submitted a claim through EDI or another process, it cannot be converted to a Real-Time Claim. If you try to do so, it will create a duplicate, which could potentially lead to confusion or claim denial. b lueshie ldca.c om Page 3 of 3
10. Can I submit an estimate for past, current or future dates of service?
Initially, you will be able to create estimates for past dates of service or for current services completed that day. After our second release in October 2020, you will also be able to create estimates for future dates of service up to seven (7) days in advance.
11. How long will an estimate be available?
Estimates provided via the Real-Time Claims tool will expire after seven (7) days due to the possibility of the member’s payment responsibility changing. You can generate a current estimate by resubmitting the expired estimate.
12. Is there a Real-Time Claims Reference Guide available with how-to information?
Yes, you can find it in the Real-Time Claims tool, under “Help.”